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SAN J O A Q U I N Environmental Health Department --COUNTY DAIRY FARM EMPLOYEE HOUSING ANNUAL PERMIT EXEMPTION SELF-AUDIT HOUSING INSPECTION CHECKLIST COMPLETE ONE CHECKLIST FOR EACH HOUSING UNIT FACILITY NAME: yF ,/ 1 PR#: LOCATION: Yul MAP DESIGNATION: HOUSING UNIT INFORMATION Address or identification number of unit: q Date of Inspection: Type of Housing Unit: ❑Single Family Dwelling Mobile Home ❑ Other: #Employees in Unit: Date Unit First Built or Installed: Electrical Power Provided By: �6 G Das Provided by: HOUSING UNIT INSPECTION Interior Checklist Comments Unit has hot and cold running water. BOkay ❑Needs Repair* Approved electrical power and gas fuel being supplied to Unit. (Okay ❑Needs Repair* Heater maintained in functioning and safe manner(No space/portable heaters). ©okay ❑Needs Repair* Doors and windows are accessible/operable to allow for safe exiting. ®Okay ❑Needs Repair* All rooms are clean and sanitary.No insect/rodent infestations present. ®okay ❑Needs Repair* All appliances(stove,water heaters,air conditioning units,heaters)are ®'Okay properly vented,strapped and are maintained in a safe,working order. ❑Needs Repair* All smoke and carbon monoxide detectors are present and tested to be shown Okay in working order. ❑Needs Repair* All wiring in safe,working order(no splices,exposed wires,uncovered outlets). ®"Okay ❑Needs Repair* All plumbing in safe,working order(no leaks,properly maintained). BOkay ❑Needs Repair* All counters,sinks,toilets,tubs,showers are working and in sanitary condition. okay ❑Needs Repair* All Floors,walls,ceilings are free from holes,are not sagging or buckling,have Okay no water leaks and are clean and in good condition. ❑Needs Repair* Exterior Checklist Comments Roof is properly maintained with no holes,loose shingles,leaks,etc. okay __ ❑Needs Repair* Exterior siding is maintained with no loose plaster,peeling paint,holes,etc. ©Okay ❑Needs Repair* Stairways are safe with no rotting,deteriorating,or loose parts. [20kay ❑Needs Re air Propane tank has barrier protection and"No Smoking"signage. E30kay ❑Needs Repair* The trash cans are sufficient in size,have lids and are picked up weekly. POkay ❑Needs Repair* . The electrical panel is covered and protected from tampering. ®okay ❑Needs Re air' The gas fuel connection is as approved and safe. POkay ❑Needs Repair* There are no insect or rodent infestations. ikay ❑Needs Repair* The sewage system is functioning,with no surfacing wastewater or backup, [Okay ❑Needs Repair*_ *Needs Repair:Pleasespecify date repairs to be completed.Any Building Permits required for repairs must be obtained and finaled. I certify that I have inspected the above noted unit and that the information provided is true and correct to the best of my knowledge. SIGNED: DATE TITLE 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com